PROJECT SUMMARY/ABSTRACT In the United States, more than 50% of women have pre-pregnancy overweight/obesity, and half of women experience gestational weight gain (GWG) in excess of the Institute of Medicine recommendations. Low-income and racial/ethnic minority women are disproportionately affected. Pre-pregnancy overweight and excessive GWG increase the risk for prenatal and perinatal complications. Behavioral interventions aimed at reducing excessive GWG have had limited success, particularly among women with overweight/obesity. Most GWG interventions involve high participant burden and fail to sufficiently address both the psychological (e.g., stress, low self-efficacy) and material (e.g., food insecurity, transportation) barriers and needs of low-income, minority women. One promising and novel alternative approach capable of overcoming many of these barriers is the provision of healthy, home-delivered meals. In non-pregnant populations, meal delivery has been used to help manage various conditions including overweight/obesity, type 2 diabetes, and cardiovascular disease with cost- effective and encouraging results. While the use of meal delivery for managing weight in pregnancy has not been tested, there is evidence that meal replacement shakes and bars are effective for reducing GWG. However, poor compliance to the meal replacement prescription was common. Instead, the use of culturally appropriate, home- delivered meals may be more palatable and offer a unique approach to managing GWG. Importantly, meal delivery for GWG management may be sustainable given the cost-savings demonstrated in other populations and the recent expansion by public and private insurers to cover home-delivered meals. The purpose of the proposed R21 exploratory/developmental grant is to test the feasibility, acceptability, and preliminary efficacy of a meal delivery intervention for managing GWG among predominantly African American and low-income pregnant women with overweight/obesity using a rigorous and efficient quasi-experimental design. In particular, the specific aims of this project are to: 1) explore the feasibility and acceptability of the meal delivery intervention; 2) investigate the preliminary efficacy of the meal delivery intervention on GWG and estimate the effect size of the intervention relative to a non-randomized but weighted standard care control group derived from de-identified hospital records; and 3) investigate pre- to post-intervention changes in patient-reported food insecurity, stress, diet satisfaction, self-efficacy, and diet quality. This project will provide essential data to inform the design of a future large-scale and fully-powered randomized controlled trial on the effectiveness and cost of the meal delivery intervention on GWG adherence and maternal-child health outcomes. Ultimately, results could inform public policy to leverage existing programs (e.g., supplemental nutrition assistance programs) and/or modify insurance coverage to promote sustainability, which would have a meaningful public health impact on maternal-child health.

PROJECT NARRATIVE Existing behavioral interventions have largely failed to produce substantial improvements in gestational weight gain adherence and, in turn, perinatal outcomes, in part due to high participant burden and failure to address the psychological (e.g., stress, low self-efficacy) and material (e.g., food insecurity, transportation) needs of low-income, minority women. The provision of healthy, home-delivered meals overcomes many of these treatment barriers that disproportionately burden underserved populations. This project will test the feasibility, acceptability, and preliminary efficacy of a meal delivery intervention targeting gestational weight gain among predominantly African American and low-income pregnant women with overweight/obesity.